Winfrith House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Leadership and governance arrangements did not provide effective oversight. Systems to monitor risks, staffing, medicines, safeguarding, and care quality were ineffective. Audits were absent or incomplete, incidents were not consistently analysed for themes or learning, and action was not taken to address identified shortfalls.

The provider had not addressed breaches identified at previous inspections, which demonstrated a failure to embed learning and improvement. The registered manager’s dual registration across 2 services, combined with limited oversight from the nominated individual, reduced leadership capacity to effectively discharge their legal responsibilities. These governance failures undermined confidence in the provider’s ability to sustain improvement and placed people at ongoing risk of unsafe and inconsistent care.

The provider was in breach of the legal regulation good governance.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders and staff did not consistently promote a shared vision or culture that prioritised high-quality, safe, and person-centred care. Staff were motivated and committed, but the absence of clear strategic direction and structured oversight limited the service’s ability to deliver consistently excellent care.

There was a lack of structured leadership and proactive culture. The absence of a consistent approach contributed to repeated shortfalls and limited opportunities for staff to be actively involved in shaping service priorities or contributing to improvement initiatives. The culture was primarily reactive, with changes often prompted by immediate issues or inspection findings rather than proactive quality improvement.

Staff dedication was evident but not supported by systems. Staff demonstrated commitment and positive engagement in daily practice. However, leaders had limited mechanisms to embed consistent standards, monitor progress, or foster shared accountability, reducing assurance that improvements would be sustained.

The provider acknowledged the need to strengthen leadership, clarify priorities, and establish structured oversight to support a shared vision and culture.

Leaders did not have the capacity, knowledge, or experience to consistently deliver safe, person-centred care. Breaches of legal regulations and significant concerns were identified across areas including safe care, person-centred care, and governance.

There was limited leadership capacity and oversight. The registered manager explained that dual registration across 2 services and being the sole 24/7 on-call manager limited their capacity to implement effective systems. Key governance tasks, including monitoring care plans, completing audits, and reviewing staff competencies, were incomplete or undertaken reactively rather than through a structured quality assurance framework.

The nominated individual oversight was insufficient. Although described as supportive, the nominated individual did not routinely carry out quality assurance visits, monitor the service, or provide proactive oversight to identify emerging risks. Leaders did not consistently escalate concerns or address systemic shortfalls promptly, contributing to repeated regulatory breaches.

This lack of visible, accountable, and capable leadership reduced assurance that safe, high-quality, and person-centred care could be reliably delivered or sustained.

The provider fostered a culture where staff felt able to speak up and raise concerns without fear of reprisal. Staff reported feeling listened to and confident that leaders would act on issues related to care, safety, or workplace matters.

Positive staff culture supported openness and accountability. Feedback indicated a supportive and respectful environment that encouraged transparency and reinforced staff commitment to the service. Whilst formal systems for recording and tracking concerns were limited, the observed culture mitigated risks associated with under-reporting and promoted staff confidence in raising issues.

The provider promoted workforce diversity and an inclusive culture.

Staff told us they felt supported, respected, and fairly treated regardless of background. Leaders actively encouraged equity and inclusion in daily practice, embedding these principles into staff support, engagement, and team development.

Although formal documentation of specific initiatives was limited, staff feedback highlighted a consistently positive and inclusive work culture, contributing to morale, retention, and an effective workforce.

The provider did not have effective governance, accountability, or risk management systems. Oversight of care, staffing, medicines, and the environment was inconsistent or absent, allowing repeated shortfalls to persist without timely mitigation.

Staff management and deployment were ineffective. Records were incomplete, mandatory training was missing or outdated, competencies were unverified, and overnight staffing did not meet assessed needs. Staff arrangements did not provide assurance that care could be delivered safely and consistently.

Systems to manage medicines, care planning, and risk were inadequate. Positive Behaviour Support plans were reactive and incomplete; care plans were often outdated, and health passports were inconsistent. Medicines were stored unsafely, records contained gaps, and PRN guidance lacked linkage to care plans. Environmental and emergency systems were insufficient, including unsecured furniture, unsafe window restrictors, roof access, inaccurate fire risk assessments, and protocols reliant solely on the registered manager’s availability. Infection prevention and control monitoring, including Legionella mitigation, was limited.

Safeguarding and consent processes were inconsistent. Risks from staffing, behavioural incidents, and suspected choking were not consistently escalated. There was no safeguarding tracker, and outcomes were poorly recorded. Best interest decisions were sometimes generic, with limited evidence of involvement or adherence to the Mental Capacity Act 2005.

Reactive actions were insufficient without embedded systems. Some immediate improvements were initiated during inspection; however, without structured governance, consistent oversight, and sustained action, people remain at risk of unsafe care, inconsistent support, and repeated regulatory breaches.

In response to our findings, the provider engaged an external consultant to help drive improvement in relation to care safety and quality.

The provider did not consistently collaborate with external partners to ensure seamless care.

Information sharing and coordination were inconsistent. Health passports and care plans were not consistently updated, reducing the reliability of information provided to external services. Without robust systems for structured collaboration, people’s care and experiences may not consistently reflect their needs, particularly for those with complex requirements.

However, staff engaged effectively with healthcare professionals, including GPs, occupational therapists, intensive support teams, and social care staff. Professionals told us that staff were well-informed and responsive.

The provider acknowledged the need to strengthen partnership working, improve communication, and embed systems for structured collaboration.

The provider did not demonstrate a commitment to continuous learning or service improvement. Following the last inspection, an action plan was submitted to address regulatory breaches, however, significant shortfalls remained.

Quality assurance and performance monitoring were ineffective. The provider had not evaluated the quality or safety of the service, and previous improvements had not prevented ongoing breaches. Systems to monitor performance, identify risks, and embed learning were absent or ineffective, limiting the service’s ability to deliver consistent, safe, and person-centred care.

The absence of formal processes for learning from incidents, auditing practice, and implementing preventative measures reduced assurance that positive outcomes could be sustained or that opportunities for innovation would be identified and acted upon.